LOW BACK PAIN

You don’t have to watch a gymnast to appreciate what the back does for the human body. In addition to connecting all our parts, from the head to the pelvis, the back can make an infinite number of twists, turns, bends and stretches. It not only carries your entire upper torso, shoulders and head, it can be used to push, carry and leverage tremendous weight. In addition to supporting us and allowing us to move, the back’s spinal chord transmits signals that tell the rest of the body what to do and conveys sensations such as heat, cold and pain. And like any piece of complex machinery, the back, with its 30 bones (vertebrae) and the pads of cartilage that cushion and protect them (intervertebral discs), more than 50 nerve roots and countless ligaments, tendons and muscles, can go terribly awry just by virtue of the number of moving parts it has that must perform in harmony.

Most people have, at some point in their lives, experienced back pain that interfered with work, play or even the routine maintenance of everyday life. As a neurological ailment that causes job-related disability and missed work, back pain is second only to headaches. Americans spend over $50 billion per year on low back pain, and the suffering it causes cannot be calculated.
Most instances of acute low back pain are temporary and go away within a few days or a few weeks. When the pain persists for more than three months it is considered chronic. The cause is many times difficult to pinpoint and it can progress if not treated quickly and effectively.

What is low back pain?
The spine has four regions:
the seven cervical or neck vertebrae (C1 – C7)
the 12 thoracic or upper back vertebrae (T1 – T12)
the five lumbar vertebrae (L1 – L5), which is the lower back
the sacrum and coccyx, a group of bones fused together at the base of the spine.
The lumbar region of the back, where most back pain is felt, supports the weight of everything above it. This is the lower back.

Symptoms
Painful symptoms in this region can be
Muscle aches
Shooting, stabbing or burning pain
Limited range of motion or stiffness
The inability to stand or walk
Pain that radiates from the lower back to the hips or down the legs
What causes low back pain?
Simply the aging process can cause back pain. The muscles can weaken and lose elasticity, the bones tend to thin and become more brittle and the discs can lose fluid, decreasing their ability to protect and cushion the vertebrae.
Actions as simple as twisting suddenly or lifting a heavy object can cause a sprain, pull or spasm in a muscle or ligament in the lower back. These injuries are mechanical in nature — caused by trauma to the lower back or by osteoarthritis. Injuries that cause low back pain can occur from staying in one position too long, playing sports, being involved in a car accident or household chores. If the spine receives enough trauma or is overly compressed, a disk may rupture or bulge, pressing on any of the more than 50 nerves attached to the spinal chord. Although back pain is rare in children, an overloaded backpack used daily for school as well as obesity can cause back pain in kids. In addition, poor posture, smoking, stress, a sedentary lifestyle, improper footwear and poor sleep hygiene can cause back pain. Other causes of low back pain include:

Nerve irritation
Muscle irritation
Bone lesions
Arthritis
Disc disease
Osteoporosis
Viral infections
Irritation to joints or discs
Congenital abnormalities of the spine.
Build up of scar tissue from injuries over time

Conditions associated with low back pain
Herniated disc (also called bulging, protruding or ruptured disc). Just as the shock absorbers in a car wear out with use over time, so do the discs in the spine. From years of constant movement and pressure, the disc can degenerate or be moved in such a way that they begin to touch on a nerve root, causing pain. Studies show that most herniated discs occur in the lumbar region of the spine.
Cauda equina syndrome is a much more serious complication, in which disc material moves into the spinal canal, compressing the bundle of lumbar and sacral nerve roots of the spinal canal below the termination of the spinal cord. In addition to pain, signs and symptoms of cauda equina syndrome include sciatica, loss of sensation in the genitals, anus and inner thighs, incontinence of the bladder or bowels and sexual dysfunction. Permanent neurological damage can occur if left untreated. Surgical decompression and/or removal of blood, bone fragments and the herniated disc itself are usually necessary.
Sciatica occurs when a herniated disc presses on the sciatic nerve, which is a large nerve that extends down the spinal column bringing nerve fibers to the leg. The pain travels down the back through the buttock and as far down as the knee, occasionally reaching the foot. Numbness and loss of motor control can also occur if the nerve is pinched between the disc and an adjacent bone.
Spinal degeneration may occur over time and cause narrowing of the spinal canal. Stiffness and pain after walking or standing are symptomatic.
Spinal stenosis is a narrowing and compression of the spinal chord and nerve that can be degenerative or congenital. There is likely to be pain, weakness, tingling or radiation down the legs with lumbar spinal stenosis (LSS).
Osteoporosis (“porous bones”) is a progressive bone disease that causes reduced bone mass, density and strength, and makes one at risk for fractures of the bones of the spine and hips.
Skeletal irregularities put strain on all parts of the back and can be progressive. These include scoliosis, a curving of the spine; kyphosis, where the upper back is severely rounded; lordosis, an abnormal arch in the lower back; back extension or flexion, where the spine bends backward or forward respectively.
Fibromyalgia can cause musculoskeletal pain and tender points in the neck, spin and hips, as well as stiffness.
Ankylosing spondylitis is a chronic inflammatory disease and is a form of spondyloarthritis, a chronic, inflammatory arthritis. It affects joints in the spine and the pelvis, and can eventually cause fusion of the spine.
Irregular gait or walking disorders can produce a repetitive strain injury in the lumbar region. With careful evaluation, orthotics can correct gait in many patients with lower back pain, producing a marked reduction in pain. Legs of different lengths can also produce irregular gait and back pain, and can be addressed with orthotic shoes. Lower back pain can also cause an irregular gait, thus becoming a circular problem.

Diagnosis
Starting with a thorough patient history and physical, the physician may order blood and imaging tests in order to diagnose the source of the pain.
X-ray images may be the first tests ordered. The x-ray will show broken bones or damaged vertebrae.
Discography is an x-ray enhanced by injecting contrasting dye into a suspect disc or into the spinal canal. This method allows the clinician to see spinal cord and nerve compression.
Computerized tomography (CT) uses a computerized scanner to produce at two-dimensional visual that can determine if disc rupture, spinal stenosis or damaged vertebrae are present.
Magnetic resonance imaging (MRI) uses a strong magnetic field and radio waves to produce a two- or three-dimensional image of the body. An MRI can show bone degeneration as well as injury or disease in the tissues and nerves, muscles, ligaments and blood vessels.
Electrodiagnostic procedures such as electromyography (EMG), nerve conduction studies and evoked potential (EP) studies are used to detect and evaluate nerve damage in the muscles or muscle degeneration. These procedures can also detect lumbar spondylosis, sciatic nerve dysfunction and spinal stenosis.
Bone scans are used to diagnose infection, fractures, joint disease or disease in the bones. Radioactive material is injected into the bloodstream and collects in areas that have abnormalities. A scanner produces images of these areas that can be analyzed by the clinician.
Ultrasound imaging or sonography produces real-time images using high-frequency sound waves. It is used to detect damage or tears in ligaments, muscles, tendons and other soft tissue areas in the back.

Treatment and prevention
The cause of lower back pain is not always easy to diagnose. Obtaining a second or third opinion for back pain that has become chronic is both reasonable and recommended. A solid diagnosis is a must in dealing with lower back pain.
Most lower back pain, whether acute or chronic, can be treated without surgery. Pain relief, reduced inflammation and restored function are the goals in treating back pain.
Heat therapy works best with a moderate temperature. Never apply heat for more than 20 minutes.
Heating pads
Hot packs
Moist heat: warm towels, warm showers or bathes, a heated whirlpool
Cold therapy works by numbing the local tissue. Ice and cold packs should never be placed directly onto the skin — use a towel wrapped around the pack. Do not use cold therapy for more than 20 minutes, and be careful not to make the muscle overly cold, as making it numb increases the risk of overusing it.
Moderate, gentle exercise can strengthen the back muscles and other “helping muscles” allowing the injured area to heal. Check with your doctor or physical therapist before beginning an exercise program. Stretching before exercise is essential to prevent further damage. Swimming, walking and yoga are activities that can strengthen the back.
Proper posture and ergonomics can make a real difference in preventing, treating and managing back pain. If you work at a computer all day, make sure your monitor is the correct height, you have a high-quality chair with lumbar support and your feet are able to sit fully on the floor or on a low stool. Take frequent exercise or stretching breaks.
Invest in high-quality, appropriate shoes for all areas of your life.
Lift with the knees, and never while bending over. Always lift squarely facing what you are lifting. And just because you can lift something doesn’t mean you should. Back pain may be the result many years down the line.
Maintain proper nutrition and weight. Get enough calcium, phosphorus and vitamin D to promote bone growth.
Do not smoke. Smoking reduces blood flow to the lower spine and causes discs to degenerate.

Medications
Medications can give pain relief. If you opt for over-the-counter analgesics make sure they do not interfere with drugs you are currently taking and follow the directions carefully.
Nonsteroidal anti-inflammatory drugs (NSAIDs)  , such as ibuprofen and aspirin can provide pain relief and reduce swelling and inflammation. Topical analgesics stimulate nerve endings to produce the sensation of heat or cold and also reduce inflammation.
Anticonvulsants — drugs used to prevent seizures — are sometimes prescribed to reduce pain
Certain antidepressants, particularly in the tricyclic family, have been shown to reduce pain.
Opioids are prescribed when acute or chronic pain is severe. These drugs should be used with caution and with attention to side effects such as drowsiness, depression and potential addiction.
Spinal manipulation by a chiropractor can be a means of great relief to some people with lower back pain. However, make sure you have a solid diagnosis first, and that you physician is on board with this type of treatment.
Interventional therapy works by blocking nerve conduction between the painful element and the brain. Injection of local anesthetics, steroids or narcotics into the affected areas, including soft tissue, joints or nerve roots has shown to be effective in many cases. Overuse of steroidal injections may cause functional impairment, however. Nerve blocks and spinal cord stimulators are considered for chronic, intractable pain, as are low does of drugs administered by catheter directly into the spinal chord.
Used mostly for mild but chronic back pain, traction uses weights to give a gentle pull to the skeletal structure and realign the spine.
TENS, transcutaneous electrical nerve stimulation, is a device that can be used in the home. With small electrodes attached to the skin, it sends small electrical pulses to painful areas.
Physical therapy can teach people with chronic lower back pain how to move in a way that prevents further damage, help create a strengthening exercise program and perform therapeutic massage and movement therapy.
Vertebroplasty and kyphoplasty are minimally invasive treatments that seal fractures of the vertebrae caused by osteoporosis. With vertebroplasty the physician uses a fine needle and, guided by real-time imagery, injects a fast-hardening epoxy directly into the bone to stabilize and strengthen it, also providing immediate pain relief. Kyphoplasty uses a small balloon to inflate the bone before injecting the epoxy. This restores height to the bone and helps reduce spinal deformity.

Surgery
There are cases where surgery is the appropriate treatment. Healing from back surgery can take many months. Back surgery may cause (sometimes intentional) permanent loss of flexibility. In addition, back surgery may be unsuccessful (see failed back surgery syndrome below).
Discectomy is one of the most common types of back surgery. Its purpose is to remove debris from a herniated disc that may be pressing on the spinal cord or a nerve root. The surgeon may also remove the small piece of bone called the lamina from the vertebra in order to access the disc more easily.
Foraminotomy is a process of removing bone from the hole (foramen) where a nerve root exits the spinal canal. By making the hole larger there is less opportunity for the bone to press on the nerve. Removing this blockage relieves pressure on the nerve.
IntraDiscal Electrothermal Therapy (IDET) uses a catheter through which a needle passes and makes contact with a cracked or broken disc. The needle is then heated and the heat thickens and seals the disc wall.
Nucleoplasty, or plasma disc decompression (PDD) uses an x-ray guided probe to remove a small amount of disc tissue and then apply controlled heat to the disc. This causes the pressure inside the disc to decrease and the disc to bulge less.
Radiofrequency lesioning uses the same type of needle, but it is inserted into the nerve tissue and heated, causing destruction of the nerve.
Spinal fusion is a procedure whereby a disc is removed and the two adjacent vertebrae are fused together using bone grafts or metal devices and screws. This causes some loss of flexibility depending on how many discs/vertebrae are involved, but those with severe, intractable pain may consider it a good trade-off if it significantly reduces or completely eliminates their back pain.
Spinal laminectomy, or decompression, involves removing the lamina to increase the size of the spinal canal and relieve pressure on the spinal cord and nerve roots.

Integrative therapies
Meditation
Yoga
Mindfulness training
Cognitive-behavioral therapy emphasizing pain management
Dealing with depression
Deep abdominal breathing
Progressive muscle relaxation
Visualization and guided imagery
Tai chi
Acupuncture
Biofeedback

What is failed back surgery syndrome (FBSS)?
FBSS, or failed back syndrome, is not really a syndrome, but simply refers to chronic, severe pain after unsuccessful back surgery. There are many possible causes depending on the cause of pain and the type of surgery. There may be complications during surgery, or the original cause of pain can recur. The nerve root may not be adequately decompressed or deadened. The surgical procedure itself may irritate or damage nerve roots, or scar tissue may grow after surgery and compress the nerves. There may not be appropriate rehabilitation and physical therapy after surgery, or, if the patient’s back muscles are deconditioned, chronic pain can persist.
Spinal fusion is usually a successful procedure, but carries inherent risks of failed back surgery syndrome. The metal implants may fail after surgery, or the bones may fail to fuse. In addition, fusing vertebrae in one area of the back will put more stress on other vertebrae, which now must do more work.

Research
Researchers (most notably at or through NIH) are studying back function and low back pain in these areas:
The use of different drugs to treat back pain, in particular daily pain that has lasted at least six months.
Comparison of different health care approaches to managing acute low back pain, such as standard care versus chiropractic, acupuncture or massage therapy. These studies are measuring symptom relief, function restoration and patient satisfaction.
Comparison of standard surgical treatments to the most commonly used standard nonsurgical treatments to measure quality of life among patients with spinal stenosis.
Whether low-dose radiation can decrease scarring around the spinal cord and improve surgical outcomes.
Why spinal cord injury and other neurological changes can lead to increased sensitivity to pain, decreased pain threshold or central sensitivity syndrome.
Neuropathic pain
How fractures of the spine and their repair affect the spinal canal and intervertebral foramena (openings around the spinal roots).
Artificial spinal disc replacement surgery for patients with degenerative disc disease.

Information and resources
For more information on neurological disorders or research programs funded by the National Institute of Neurological Disorders and Stroke, contact the Institute’s Brain Resources and Information Network (BRAIN) at:

BRAIN
P.O. Box 5801
Bethesda, MD 20824
(800) 352-9424
http://www.ninds.nih.gov
Information also is available from the following organizations:

American Chronic Pain Association (ACPA)
P.O. Box 850
Rocklin, CA 95677-0850
ACPA@theacpa.org
http://www.theacpa.org
Tel: 916-632-0922 800-533-3231
Fax: 916-652-8190

National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse
1 AMS Circle
Bethesda, MD 20892-3675
NIAMSinfo@mail.nih.gov
http://www.niams.nih.gov
Tel: 877-22-NIAMS (226-4267) 301-565-2966 (TTY)
Fax: 301-718-6366

American Association of Neurological Surgeons
5550 Meadowbrook Drive
Rolling Meadows, IL 60008-3852
info@aans.org
http://www.aans.org
Tel: 847-378-0500/888-566-AANS (2267)
Fax: 847-378-0600

American Academy of Orthopaedic Surgeons/ American Association of Orthopaedic Surgeons
6300 North River Road
Rosemont, IL 60018
hackett@aaos.org
http://www.aaos.org
Tel: 847-823-7186
Fax: 847-823-8125
American Academy of Family Physicians
11400 Tomahawk Creek Parkway
Suite 440
Leawood, KS 66211-2672
fp@aafp.org
http://www.aafp.org
Tel: 913-906-6000/800-274-2237
Fax: 913-906-6095
American Academy of Neurological and Orthopaedic Surgeons
10 Cascade Creek Lane
Las Vegas, NV 89113
aanos@aanos.org
http://www.aanos.org
Tel: 702-388-7390
Fax: 702-871-4728

American Academy of Physical Medicine & Rehabilitation
330 North Wabash Ave.
Suite 2500
Chicago, IL 60611-7617
info@aapmr.org
http://www.aapmr.org
Tel: 312-464-9700
Fax: 312-464-0227
For information on clinical trials for low back pain, go to http://clinicaltrials.gov/search/term=Back%20Pain